xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23262, Wiley Online Library on [02/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

127

ICAR SINONASAL TUMORS

TABLE XIV.3 (Continued)

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Vikram et al. 548

1. Irradiation is used for advanced, inoperable ACC; it offers useful palliation but is rarely, if ever, curative 2. Postoperative irradiation, on the other hand, might improve the

1. Tumor regres sion/local control rate

1984 4

Retrospective case series

ACC at a single

institute (SNM n = 19)

local control rate and the survival in patients with

operable ACC who are at high risk for relapse, but only if the field size and the dose are adequate Abbreviations: ACC, adenoid cystic carcinoma; CCS, cystic carcinoma survival; DFS, disease-free survival; G3 + tox, grade 3 plus toxicity; LC, local control; LRC, local–regional control; NRT, fast neutron therapy; OS, overall survival; PFS, progression-free survival; SNM, sinonasal malignancy.

Radiation modalities for treatment of sinonasal malignancies

In summary, retrospective cohort studies show that CIRT can improve LRC, DFS, and OS rates in SNM, with the magnitude of the benefits dependent on the extent of disease and pathology of the primary malignancy (Table XIV.4). Its role as monotherapy or in combination with PBT or IMRT is currently being studied. The question of improved disease control compared to other radiation techniques for those with radioresistant pathologies such as ACC is currently being studied. No randomized trials address the topic of advanced RT modalities for SNM, and only two multimodality system atic reviews are available, which are limited by significant heterogeneity and patient numbers. Despite these limita tions, the evidence, predominantly from single-institution retrospective series, supports the use of IMRT and PT (specifically NRT, PBT, and CIRT) as the standard of care for RT modalities for primary or adjuvant therapy of SNM to improve LC, DFS, and OS rates. The presence and magnitude of the absolute benefit from primary or adjuvant radiotherapy are based on the extent of resid ual disease, pathology, and pathology-specific factors. The highest level of reported evidence shows PT (particularly PBT) improves LRC and DFS rates over IMRT. Preliminary cohorts using CIRT suggest a potential benefit beyond PBT, particularly with radioresistant pathology. While some series show concern for a higher side effect profile with NRT, there have been no modern experiences reported. There is limited evidence that compares acute and late tox icity profiles and events between treatment modalities, nor are there differences in oncologic outcomes among PT.

Aggregate grade of evidence

IMRT: B (Level 2: three studies; Level 3: one study; Level 4: 50 studies) PBT: C (Level 2: two studies; Level 3: one study; Level 4: 23 studies); five level 4 CIRT series include single modality PBT patients NRT: C (Level 4: 10 studies) CIRT: C (Level 2: two studies; Level 3: two studies; Level 4: 23 studies) IMRT provides LRC and benefits in PFS and OS rates as either primary or adjuvant therapy for SNM with absolute benefits RT morbidity is related to the extent and site of the tumor, including soft tissue, bone, vascular, and neural injury. Aside from IMRT, the other modalities may not be widely available, and patients may need to travel to specialized facilities for care. Limited to two series. PBT provided extra QALY compared to IMRT and was cost-effective in patients ≤ 56 years old and CIRT increased costs compared to IMRT despite survival benefits. Preponderance of benefits over harms. dependent on patient- and pathology-specific factors.

Benefit

Harm

Cost

Benefits–harm assessment

(Continued)